HSS CPOC Service Annual Report 2021
Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Highly Specialised Services (HSS) Colorectal and Peritoneal Oncology Centre (CPOC) The Christie Hospital
Report 2021
The Christie NHS Foundation Trust Wilmslow Road Withington Manchester M20 4BX http://www.christie.nhs.uk/cpoc
Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Contents 1
Introduction
3
2
Workforce/infrastructure development
4
3
Impact of Covid-19 pandemic
7
4
Patient and Public engagement 4.1 Patient Day 4.2 Nurse-led follow up service
11 14 15
4.3 e-PROMS
5
Education and Training, Research 5.1 Education and training
16 19 19 20 20 21 22 23 25 25 25 26 26 28 30 31 32 33 34 35 37
5.2 Research
5.2.1 Biomarker research 5.2.2. Technology and innovation
5.2.3 Clinical outcome and treatment effects
5.3 Conferences + Meetings 5.4 Project grants and awards 5.5 Publications from 2019 to 2021 5.6 Books/Chapters written The Peritoneal Tumour Charitable fund 6.1 Increased awareness 6.2 Improving the patient journey
6
6.3 Introducing a health and wellbeing programme 6.4 Introducing the CPOC Academy lab
7
Unit data 7.1 Referrals
7.2 Demographics
7.3 Assessment and treatment
7.4 Specialist commissioning (appendix) assessment/follow up activity
7.5 Quality
7.6 Completeness of Cytoreduction scores
7.7 Complications
7.8 Survival
Appendix I: Procedure activity
39
Appendix II: PCI and CC scores by disease group
42
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
1. Introduction The Christie Colorectal and Peritoneal Oncology Centre (CPOC) Peritoneal tumour Service (PTS) experienced a reduction in referrals with regard to the appendiceal tumour activity compared to the year 2019-2020 (259 and 278 respectively); whereas the referrals concerning patients with colorectal peritoneal metastases (CRPM) marginally increased (198 versus 196 respectively). This translated into 121 appendiceal procedures and 67 CRPM procedures, compared to 130 and 62 respectively in 2019-20. Considering the need to provide an additional 70 colorectal cancer resections whilst acting as a Covid “green site” for Greater Manchester, as well as the restrictions placed on the unit due to the Covid-19 pandemic, the team have worked extremely effectively in often very challenging circumstances over the last year. We have been delighted to welcome our 2 new consultant colleagues, Rebecca Fish who joined in October 2020 and Paul Sutton who joined in February 2021. In addition, we were joined by the 1 st ACPGBI/RCS Advanced Colorectal Malignancy fellow Sarah Hassan who is spending a year from October 2020 with us. We currently have 5 of our staff undertaking the ESPO fellowship in peritoneal surgery. Our results continue to indicate a high-quality service. For those with appendiceal neoplasia undergoing CRS and HIPEC, 77.9% have had a CC0/1 cytoreduction and patients with colorectal peritoneal metastases 83.6% had CC0/1 cytoreductions. Overall, our minor and major complication rates remain within and compare favourably to the internationally published data, with 29.2% having minor (G1/2) complications and 13.8% having G3/4 complications over the past 12 months. There was a single (0.52%) 90-day mortality. The unit has now performed 81 laparoscopic risk-reducing CRS+HIPEC with no complications in 80.3%, 6% G3/4 complications and no 90-day mortalities. 5-year overall survival in patients with benign appendiceal, malignant appendiceal and colorectal peritoneal metastases are calculated to be 86%, 64% and 37% respectively. We now have sufficient data to produce Kaplan Meier curves up to 72 months’ post treatment. As in the rest of the NHS, The Christie Hospital has been significantly affected by the Covid 19 pandemic. Thankfully there have been relatively few infected patients that have passed through the trust. By pursuing a very careful level of biosecurity that has included all staff wearing PPE in all clinical areas and undergoing weekly swabbing to detect Covid (PCR tests), all in-patients being swabbed within 5 days of any surgical procedure and then again on days 3 and 7 post-operation, admitting the majority of patients on the day of their surgery, prevention of all visitors and a dramatic increase in the number of remote consultations, using telephone and video communications, we have only needed to close the main ward on a single occasion for 8 days in December. We have had a successful year with regard to our research and training activities in spite of being unable to visit meetings or other units. Over 2020-2021 the group has obtained nearly £4million of funding for a variety of projects, both clinical and laboratory based. The unit has published 18 separate papers in peer reviewed journals since 2019. Our charity continues to provide us with significant support to allow us to develop our research and also to add to our patients’ and their families experience. MS Wilson May 2021
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
2. Workforce
Name
Job Title
Mr MS Wilson
Consultant Surgeon/ Lead Clinician for PTS service
Prof ST O’Dwyer
Consultant Surgeon
Prof AG Renehan
Professor of Cancer Studies and Surgery, Honorary Consultant
Mr CR Selvasekar
Consultant Surgeon/ Associate Medical Director CSSS
Mr O Aziz
Consultant Surgeon/ Lead Clinician Colorectal service
Mr H Clouston
Consultant Surgeon
Mr JRL Wild
Consultant Surgeon
Ms R Fish
Consultant Surgeon
Mr P Sutton
Consultant Surgeon
Mr R Deshpande
Consultant Hepatobiliary Surgeon
Prof MP Saunders
Consultant Oncologist
Dr S Mullamitha
Consultant Oncologist
Dr M Braun
Consultant Oncologist
Dr J Barriuso
Consultant Oncologist
Dr R Kochhar
Lead Consultant Radiologist
Dr D Mullan
Consultant Radiologist
Dr V Kasipandian
Lead Consultant Anaesthetist/ Inpatient Clinical Lead
Dr B Chakrabarty
Lead Consultant Histopathologist
R Halstead
Lead Clinical Nurse Specialist
L Wardlow
Clinical Nurse Specialist
R Connolly
Clinical Nurse Specialist
A Coop
Clinical Nurse Specialist
F Akhtar
Clinical Nurse Specialist secretary
R McAllister
Surgical Theatre Manager
S Madden
HIPEC Service Manager
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
A Colclough
HIPEC Practitioner
P Kennedy
HIPEC Practitioner
R Wood
HIPEC Practitioner
S Wroe
Service Manager
P Diez Echave
Data Manager
H Marley
Administration Support Manager
G Harrison
Medical Secretary
B Tyrrell
Medical Secretary
A White
Medical Secretary
G Barrett
Medical Secretary
M Cunningham
Medical Secretary
M McKenna
Medical Secretary
L Malcomson
Research Associate
L Evans
MDT Co-ordinator
Consultants We have 8 WTE consultants. In the last year we have expanded our consultant workforce with the appointments of Rebecca Fish, who joined us in October 2020, and Paul Sutton who started his post in February 2021. Professor Sarah O’Dwyer has decreased her clinical commitments in 2020 2021 to allow time for academic pursuits which will include projects dedicated to investigating
potential novel treatments for PMP. Clinical Nurse Specialists (CNS) This team has continued to remain stable over the past 12 months. Admin/Secretarial service
We successfully recruited Paul Diez Echave as Data Manager who has replaced Jacinth Kilmartin. We now have full complement of medical secretaries with further cross-cover required in order to provide secretarial support for the new consultant appointments. Managerial staff Although the managerial staff have remained stable during the last 12 months, our service manager covers other roles across the surgical division, and we still do not have a dedicated PTS manager.
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Infrastructure development Through a joint venture with The Christie NHS Foundation Trust and HCA The Christie Private Care, there has been an increase in operating theatre capacity with two new operating theatres going live in October 2020. These theatres are fully integrated with the state-of-the-art Olympus ENDOALPHA system, including 4K ultra high-definition, 3D and fluorescent imaging capabilities in addition to the nCare and VaultStream image recording and medical content management system. The new theatres have increased the number of surgical theatres to 7 in addition to separate endoscopy and day case theatres. In addition, a new day of surgery unit (DOSA) also opened in August 2020 with an increasing number of selected PTS patients now being admitted on the day of surgery. A significant infrastructure development at The Christie is the £150M Paterson Redevelopment Project. Despite the COVID-19 pandemic, building work continues on this new world-class transformational cancer research facility which will be one of the largest of its kind in Europe and will provide an exciting opportunity for members of CPOC to collaborate with leading cancer research scientists and help fulfil the unit’s research ambitions. It is anticipated the Paterson Building will be completed in 2023.
Sarah Madden - lead perfusionist, Rebecca Halstead – lead CNS, Christie Bear, Vidya Kasipandian - consultant anaesthetist
One of the 2 new operating theatres (photo courtesy of The Christie Private Care, HCA)
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
3 Impact of Covid-19 pandemic In March 2020 a global pandemic was acknowledged and NHS England issued guidance for preparation of The NHS to prepare for the exponential rise in cases expected based on the epidemiology of the disease noted from countries in Asia and Europe. The re-allocation of workforce and estates to increase ventilator capacity had a significant consequence for the elective surgical services. At The Christie, anaesthetic services were significantly affected due to re-deployment in support of acute COVID sites. The operating capacity for the CPOC team suffered a 45% reduction in operating theatre capacity. In parallel NHSE, the Royal Colleges and professional associations issued guidance relating to surgical practice during the COVID pandemic. This led to the adoption of NHSE guidance for prioritisation for surgery defined as: - • Priority level 1a: emergency operation needed within 24 hours to save life • Priority level 1b: urgent operation needed with 72 hours • Priority level 2: elective surgery/treatment with the expectation of cure needed within four weeks to save life/stop progression, taking into account symptoms and potential complications from lack of treatment • Priority level 3: elective surgery can be delayed for 10 to 12 weeks and will have no predicted negative outcome We agreed that P1 and P2 cases would continue but also recognised that a significant number of the Highly Specialised and Specialised commissioned case load fell into the P3 group. Cases were evaluated through the MDT and listed for the surgery as dictated by their disease independent of COVID and allocated a P level. Towards the end of April 2020, Greater Manchester Cancer created a Surgical Hub service to allow time critical cancer surgery to be offered on a ‘Covid free’ site. The Christie became the designated site to treat patients requiring Level 2/3 post-operative critical care support. During this time 70 primary colorectal cancer patients were operated on by Christie colorectal consultants at The Christie who would normally be operated on by other providers. As there had also been NHSE guidance regarding cancer treatments during the pandemic, which included deferring systemic anti-cancer treatment unless considered time critical, the peritoneal MDT concluded that it would be best to suspend HIPEC but that it remained appropriate to offer CRS in individual cases of appendix and colorectal cancer. We took the decision to stop using HIPEC in all of our patients on 8/4/20, with the last case to receive HIPEC being operated on in late March. We restarted HIPEC on 18/5/20 after achieving a consensus from the other UK and some European sites. Since that date all HIPEC procedures have been performed using the “closed technique” in order to reduce the risk of aerosol generation. This has now become the new normal for our surgeons. Following this change in practice we are now undertaking a comparative audit of closed versus open HIPEC delivery to ensure patient safety. Provision of the service continued apart from a break when all major surgical, non-emergency activity was stopped for 2 weeks to allow control to be achieved of an outbreak of Covid on the surgical ward in December 2020. No patients had significant damage as a result of catching Covid
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
and there have been no further cases since this. No patient receiving cytoreduction and HIPEC contracted Covid whilst being an in-patient at the Christie. All patient facing staff at The Christie are tested once a week with PCR tests, patients are tested prior to admission to the hospital, on admission and once a week thereafter whilst an inpatient. This protocol has allowed us to largely maintain a Covid secure environment and allowed the outbreak on the surgical ward to be rapidly identified and controlled. Once we had restarted the HIPEC service the level of surgical cytoreductive activity returned to pre-covid activity levels with operative monthly activity returning to the same rate as 2019/20 after the initial period in May when activity was reduced with the total level of activity being 121 in 2020/21 vs 130 in 2019/20 and 102 in 2018/19. Referral activity for the specialist commissioned services was consistent throughout the Covid period compared to the 2 previous years. This probably reflects that these patients are diagnosed either by being symptomatic or as a result of appendix specimen histology following emergency appendicectomy. CRPM activity, including both referrals and surgery, reduced during the initial phase of the pandemic. This may have reflected the delay of surveillance scans undertaken on these patients in their local hospitals after their previous surgery. The level of referrals has increased since the beginning of 2021 but the total number of referrals is still down for 2020/21 (144) vs 173 for 2019/20 and 187 for 2018/19. By the end of March 2021, the number of CRPM cytoreductions with HIPEC was 67, compared to 62 over the same period in 2019-2020.
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Specialist Commissioned Referrals
100 150 200 250 300
2018/19 2019/20 2020/21
0 50
July
May
June
April
March
August
January
Febuary
October
December
November
September
CRPM Referrals
100 120 140 160 180 200
2018/19 2019/20 2020/21
0 20 40 60 80
July
May
June
April
March
August
January
Febuary
October
December
November
September
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Specialist Commissioned Surgery
100 120 140
0 20 40 60 80
2018/19 2019/20 2020/21
July
May
June
April
March
August
January
Febuary
October
December
November
September
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
4 Patient and Public Engagement
4.1Patient Day Since 2016 we have been holding an annual patient day at The Christie. We had 113 registered for our patient day in April 2020, but sadly this could not go ahead due to COVID-19. In April of this year, the same restrictions applied and we held our support day virtually so our patients still felt supported in some way. We had 3 patients attend our auditorium to share their stories, presentations from our physiotherapists, a clinical psychologist and Consultants from the team. The day included a live question and answer session. 34 patients signed on virtually and despite not being able to network with each other, we received overwhelmingly positive feedback. As a result of this, when we can resume our support day face to face, we will continue the virtual platform alongside it so those who cannot make it to The Christie can still benefit from the day. Our next day is planned for the 21 st of April 2022. Here are some of the comments from our first virtual patient support day: “Once again a very interesting and moving day. Stories of hope and courage that inspire. The day makes me feel like I’ve got a support network that is so comforting. The dedication of the Christie Team is humbling. Thank you to Rebecca for creating a platform that we are able to express ourselves, understanding our disease and treatments available.” “Great to hear other peoples’ journeys as they differ so much yet also have so much in common. Helps me to feel less isolated”. “A great event! Event was well thought through and executed. An enjoyable and insightful day!” “This was my first patient day and I am so impressed. It’s given me a real lift and made me feel so much more empowered in my treatment and care.” “Very informative, supportive and uplifting. In the absence of not being able to arrange a face to face day, this was the next best thing.” “Great having it online as I live 350 miles from Christie's” “We found the day extremely informative and helpful, hopefully next year we will be able to “The day lacked the important issue of "mingling" and sharing experiences with others which can be really supportive. However, in the circumstances the on line day was excellent” “Really useful blend of the medical information/expertise and patient experience” “Stories of hope and courage that inspire” “It made me feel so much more empowered in my treatment and care” “Given the difficult circumstances the patient day was an absolute success, well done to everyone involved” meet face to face and exchange experiences” “Very informative supportive and uplifting”
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Patient Day programme
Peritoneal Tumour Service Patient Day Thursday 8 th April 2021 Auditorium, Education Centre, Dept 17, The Christie
Introduction
09.55 10.00
Welcome
Mr Wilson (Consultant) Peritoneal Tumour Service Lead
Patient Story
10.15 10.45 11.15 11.30
Becky
Physiotherapist – Exercise and You
Seema Rahman
Coffee Break
Research
Professor O’Dwyer (Consultant)
Patient Story
12.00 12.30
Georgia
Caring for your psychological well being
Robin Muir (Clinical Psychologist)
Lunch
13.00 14.00 14:30
Patient Story
Susan
Live Q&A Session (If you would like to ask an anonymous question please use your smart phone and go onto www.sli.do event code: #PTPS )
Mr Wilson Professor O’Dwyer Mr Clouston
Roger Spencer (Chief Executive)
Close
15:00
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
2021 Patient day outcomes
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
Excellent Very Good Good
How would you rate the day overall?
What did you think of the content?
2021
2019
Not Satisfactory
Good
Very good
Excellent
Not Satisfactory
Good 10%
Excellent
How would you rate the day overall? What did you think of the content? How informative was the day? How supportive did you find the day?
0%
3%
10%
87%
0%
90%
0%
3%
7%
90%
0%
26%
74%
0%
3%
13%
84%
0%
23%
77%
0%
13%
3%
84%
3%
10%
87%
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00%
Excellent Good Very Good Fair
How beneficial was the day online?
How did you find the visuals?
How did you find the sound?
Yes
No
Blank
Did you feel you were able to interact as much as you wanted to using slido? When we do our next face to face patient day, would you like the option to view online?
68%
22%
10%
97%
3%
0%
Presentation from the Physiotherapy Department, Patient Day 2021
4.2Nurse led follow up service Our telephone follow-up service was set up in 2013 and this is now completely nurse led. 629 Clinical Nurse Specialist (CNS) follow up consultations were performed in the last year. We have sent out a satisfaction survey to 106 patients on the 20 th of April 2021 in order to identify possible unmet needs of patients and to see if we can improve the clinics further. We now offer this service
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
virtually via the NHS video conferencing link and it has been positively welcomed by many patients. The CNS’s now have a nurse led clinic twice a month which is done face-to-face. Due to COVID 19 it has been done over the telephone or virtually. This is a good opportunity for patients to have some time with their CNS to not only discuss their results and follow up but any issues they may be having that are affecting their quality of life. The clinics are also used to discuss the holistic needs assessment completed by patients prior to their appointment, formulate a care plan with the patient and sign post them to supportive services. 4.3ePROMS (electronic Patient Related Outcome Measure Service) The Christie have developed an electronic quality of life questionnaire using a platform called ePROMS to improve patient outcomes. This enables patients to complete the questionnaire using a specific online application which is quick and easy to use. An example of a typical question frame is shown below: -
The answers are colour co-ordinated with a key providing patients with advice if they are having problems which they should seek help for. The peritoneal tumour service has been one of the first to bring this to surgery and it will be piloted on patents operated on between 2019 and 2020 in June 2021. The results can be accessed by Clinicians via the individual patient’s records on our patient portal (CWP). Going forward patients will then receive this at years 1, 3, 5 and 10.
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
5 Education and Training, Research 5.1Education and Training
There is no doubt that the COVID situation has had a major impact on education and training with many of the professional meetings postponed/ suspended during 2020. Despite these difficulties we have managed to recruit to our Clinical Fellowships both in the UK and overseas. In 2020 we were successful in a bid to launch a new Fellowship: RCS/ACPGBI Advanced Colorectal Malignancy Fellow branded through the Royal College of Surgeons and the Association of Coloproctology of GB&I. The current fellow Sarah Hassan will complete her term in September 2021. We continue to support International fellows from India through The Ganga Ram Fellowship programme and from Sri Lanka: all of which have continued despite Covid restrictions. European Society of Surgical Oncology (ESSO) ESPO Fellowships: The unit has been designated by ESSO for Training in Peritoneal Oncology. Since 2015 there have been 9 Fellows registered at The Christie: • EPSO/ESSO Graduates : Andreas Larentzakis Washington November 2016: Consultant Surgeon in Greece. Adam Stearns, Paris September 2018: Consultant Surgeon in Norwich Paul Sutton, February 2021: Consultant at The Christie NHSFT • Current Fellows : Hamish Clouston, Jonathan Wild, Rebecca Fish: Consultants at The Christie Brett Winter-Roach and Rebecca Faulkner: Consultant Gynaecologists. Some progress has been hampered by the restrictions due to Covid for ESSO to run courses but it is expected that the Fellows should graduate over the next two years. The RanD Academy Unfortunately, we have been unable to collaborate during Covid for most of the major projects in this programme. However, the relationship with The King Hussein Cancer Centre in Amman, Jordon sponsored by The RanD Academy has continued through the completion of a twelve month clinical fellowship by Basim Aljalabneh. In June 2020 Professor O’Dwyer was also invited to speak in an international Webinair discussing the Prodige 7 trial debating the influence of the trial and implications for HIPEC. In March 2021 Professor O’Dwyer was nominated by The Dukes Club ACPGBI as an inspirational trainer and pioneer for surgical treatment of peritoneal tumours.
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Education/Courses The previously sponsored annual meeting/education event was suspended in 2020 but has been rescheduled for 24 th June 2021 as a Teams meeting entitled: Appendix Tumours: Who to refer and what to expect: Mr Wilson is the principle organiser and Chair of the meeting .
Academic meetings In 2020 Mr Aziz instituted monthly academic meetings which have successfully included both clinical and laboratory subjects. There was a suspension over the first Covid wave but laterally they have recommenced. Key relevant topics relating to the peritoneal service has included: • ‘Tumour Microenvironment’ themed meeting. “The Role of JAK/STAT3 cascade in colorectal cancer" presented by Professor Joanne Edwards (University of Glasgow). “Is the microenvironment the key to stratify patients with CRPMs?" presented by Dr Jorge Barriuso, May 2021 • “Investigating radiotherapy induced immune changes in rectal cancer and bowel toxicity: TIMM RAD Study summary” Professor Tim Illidge. “Lessons learned from advanced cancer fellowship at RPA Sydney” Mr Paul Sutton, April 2021 • Histopathology and Classification of Appendiceal Tumours Dr B Chakrabarty March 2021 • Prodige 7 trial paper & NIHR EVidencE Review of PEritoneal Tumour (EVERPET) project Mr Aziz , Prof Kurunchi February 2021
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
• Proteomics: Potential for advanced biomarker discovery. Dr. Richard Unwin (Deputy Director, Stoller Biomarker Discovery Centre) & Professor Paul Townsend (co-Director of Manchester Centre for Cellular Metabolism), University of Manchester. February 2020 Invited Talks Sheffield Colorectal MDT 2021 “ Colorectal Peritoneal Metastases: When to Refer” (J Wild) Doctors Academy FRCS Section I Course, 2021 “ Colorectal Surgery for the FRCS” (J Wild) Doctors Academy FRCS Section II Course, 2021 “ Lower Gastrointestinal Surgery ” (J Wild) ACPGBI/RCSEd Webinar 2020, “ Key aspects to consider in the management of appendix pathologies ” (O Aziz) RSM Section of Coloproctology Webinar 2020 “ FRCS candidates: How to survive part 3” (S O’Dwyer) Advances in Colorectal Cancer Ganga Ram Hospital Delhi, India, 2020 “ The MDT for advanced disease” (S O’Dwyer) Advances in Colorectal Cancer Ganga Ram Hospital Delhi, India, 2020 “Extended pelvic resections for rectal cancer” (S O’Dwyer) Advances in Colorectal Cancer Ganga Ram Hospital Delhi, India, 2020 “Cytoreductive surgery indication and outcomes ” (S O’Dwyer) Advances in Colorectal Cancer Ganga Ram Hospital Delhi, India, 2020, “ Robotic Training the trainer” (C Selvasekar) Doctors Academy FRCS Section I Course, 2020 “ Colorectal Surgery for the FRCS” (J Wild) Doctors Academy FRCS Section II Course, 2020 “ Lower Gastrointestinal Surgery ” (J Wild) The Christie School of Oncology Oct 2019 “ Colorectal Peritoneal Metastases: What you and your MDT need to know. Role of laparoscopy in CRPM” (J Wild) Dukes Club / ACPGBI Advanced Colorectal Cancer Day 2019 “ Cytoreductive Surgery & HIPEC” (J Wild) Dukes Club Advanced Cancer Study Day 2019, “Management of appendix tumours” ( P Sutton) The Christie School of Oncology Oct 2019, “Colorectal Peritoneal Metastases: What you and your MDT need to know: Recent evidence, new developments & referral guidelines for CRPM” (O Aziz) RandD Webinar 2019, “Analysis of Prodige 7 and implications for HIPEC in CRC” (S O’Dwyer) Training Courses FRCS (Gen Surg) Exit Exam Viva Course (April 2021), Virtual, (C Selvasekar)
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
ALSGBI LapPass course (March 2021), Regional Laparoscopic Training Day, Whiston Hospital, Merseyside (C Selvasekar) MCh virtual teaching (2020-21), Edge Hill University (C Selvasekar) ALSGBI Basic Robotic Course (Dec 2020), Northwick Park & St Mark’s Hospital, Middlesex (C Selvasekar) Key Skills Course: 6th, 7th and 8th November 2020 (Nov 2020) (C Selvasekar) MRCS OSCE Preparation Course (RCSEd) (Sept 2020), Apollo Buckingham Health Science Campus, Crewe (C Selvasekar) FRCS (Gen Surg) Exit Exam Viva Course (Sept 2020), Apollo Buckingham Health Science Campus, Crewe (C Selvasekar) MRCS OSCE Preparation Course (RCSEd) (Aug 2020), Apollo Buckingham Health Science Campus, Crewe (C Selvasekar) 5.2Research We continue to expand our research portfolio. Over the past year we have established The Christie Colorectal and Peritoneal Oncology Centre (CPOC) Academy and Lab, at the Manchester Cancer Research Centre. Despite the challenges of the pandemic, we have grown our collective research team which now comprises of; 5 PhD students, an academic clinical lecturer (50% clinical/50% academic), 2 postdoctoral research fellows, and a research manager. This team is funded through the grants listed in section 5.5. Our key research themes include: (i) Biomarker research (ii) Technology and Innovation (iii) Clinical outcomes and treatment effects 5.2.1Biomarker research Cancer Research UK Accelerator Award: Pseudomyxoma peritonei: building a European multicentric cohort to accelerate new therapeutic perspectives – We are one of three European groups (including Italy and Spain) that have been awarded this prestigious award to accelerate the collection of a comprehensive biobank of tissue from patients with pseudomyxoma peritonei (PMP) from Low-grade appendiceal mucinous neoplasms (LAMNs) over 5 years. The £2.5m award aims to identify genomic biomarkers, build in vitro 3-D models and organoids, and ultimately establish a platform to identify therapeutic options for PMP patients. Our team includes faculty from across The University of Manchester including; CPOC Lab at The Manchester Cancer Research Centre, Wellcome Trust Centre for Cell Matrix, School of Pharmacology, and Manchester Centre for Genomic Medicine. The project has to date established a standardised biobank collection process, tumour sampling, DNA and RNA extraction across the 3 countries. We are now looking to standardise live tissue processing and cell culture leading to the development of LAMN in vitro models and organoids. Ultimately this project will lead to the establishment of libraries of information that can be shared with researchers across the world to accelerate our understanding of LAMNs leading to PMP.
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
Dysregulated pathways in ColoRectal cancer Peritoneal Metastasis (CRPM): Funding secured from The Christie Charity has allowed us to establish our CRPM biomarker research program. Our comprehensive analysis of samples from peritoneal metastases with their matched colorectal cancer primaries obtained during cytoreductive surgery has been tested and validated leading to the identification of 20 genes dysregulated in peritoneal metastases that promote an early increasing role of "stemness" in conjunction with tumour favourable inflammatory changes. Our findings have indicated that the activation of these pathways, and adaptation to the peritoneal-specific environment are key to early stages of peritoneal metastasis. We are now focusing on increasing our sample size, looking for prognostic signatures, and exploring these pathways to look for therapeutic options. 5.2.2 Technology and Innovation Mass Spectrometry to characterise lipid profiles of CRPM: Mass spectrometry is a very powerful tool, used to rapidly and reliably characterise tissue. We have established a partnership between Waters Corporation (A leading mass spectrometer manufacturer), The University of Manchester, and The Christie CPOC to characterise colorectal peritoneal metastases using this powerful tool. Funded by the Medical Research Council, we have a PhD student whose project involves characterising the lipid profiles of these tumours. This is a platform for future research in this area which has implications not only for the understanding of the peritoneal environment as a metastatic site, but also for the development of rapid tools that tell the surgeon in real-time whether a tissue is ‘tumour’ or ‘normal’. The project aims to have a mass spectrometer installed in an operating theatre for real-time tissue characterisation. Prehabilitation with wearables before CRS/HIPEC: A randomised controlled pilot study. Having undertaken a systematic review of prehabilitation programs in abdominal cancer surgery, we have designed and completed the first randomised controlled trial of prehabilitation delivered solely with wearable devices versus standard of care in patients undergoing CRS/HIPEC. Funded through a donation from the charity ‘Pseudomyxoma Survivor’, we were able to achieve 67% recruitment. The prehabilitation group engaged in more daily minutes of moderate and vigorous physical activity compared to controls. They also had significantly greater improvements in the distance they could walk in 6 minutes compared to controls (+ 85.6 m vs + 13.23 m, p = 0.014]. We are now in the process of designing a larger randomised control trial in this group to quantify the impact of this improvement on post-operative recovery. 5.2.3 Clinical outcomes and treatment effects EVidencE Review of PEritoneal Tumours (EVERPET) This a 3-year NIHR-funded project between University College London and The Christie CPOC that started in 2019. This project aims to comprehensively evaluate the evidence for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases of colorectal, ovarian, gastric and appendiceal origins through individual patient data meta-analysis of clinical We continue to publish and share our outcomes with the international community. Projects include indications and outcomes for repeat CRS/HIPEC in peritoneal surface malignancy, Referral pathways and outcome of patients undergoing CRS/HIPEC, and Radiological patterns of recurrence after CRS/HIPEC for CRPM. Early identification of LAMNs at risk of PMP: We have one of the world’s largest patient groups with early LAMNs referred through our established network over the past decade. Our research in this area includes: The Long-term outcomes for pTis and pT3 non-perforated LAMNs on an active surveillance pathway and trials. More information can be found at: https://everpetwg.com/ Outcomes research for patients with peritoneal metastasis :
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
outcomes from Laparoscopic CRS/HIPEC for perforated LAMNs. We are a major contributor to the PSOGI international collaborative laparoscopic CRS/HIPEC registry which has for the first time
published its results in 2020. 5.3Conferences & Meetings 5.3.1 ACPGBI Annual Conference 2021
“Intraperitoneal Disease-Free Survival after complete cytoreductive surgery and HIPEC for colorectal peritoneal metastases”.(Published) (H Clouston, J Convill, O Aziz, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A Renehan) “Complications following complete cytoreductive surgery and HIPEC for colorectal peritoneal metastases: a UK national treatment centre experience compared with recent trial outcomes”. (Published) (H Clouston, J Convill, O Aziz, M Saunders, J Barriuso, M S Wilson, Sarah O’Dwyer, A Renehan) “Average cumulative relative dose (ACRD) of adjuvant chemotherapy is more important than average relative dose intensity (ARDI) for colorectal cancer survival, with implications for treating obese patients: the OCTOPUS consortium”. (Poster) (C Slawinski, L Malcomson, H Guo, J Barriuso, A Harkin, T Iveson, R Glynne-Jones, C van de Velde, A Renehan) “The molecular biology of synchronous primary colorectal cancer and their peritoneal metastases treated with Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)”. (Published) (J Barriuso, RT Nagaraju, S Belgamwar, B Chakrabarty, DG Evans, MP Saunders, S O'Dwyer, O Aziz) “Radiological patterns and timing of recurrence following complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with Colorectal Cancer Peritoneal Metastases”. (Published) (S Hassan, Y J Soh, O Aziz, H Clouston, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A G Renehan, R Kochhar) “Long-term outcomes for pTis and pT3 non-perforated low-grade appendiceal neoplasms on an active surveillance pathway”. (Published) (C Tan, B Chakrabarty, J Wild, C Selvasekar, A Renehan, H Clouston, M Wilson, S O’Dwyer, O Aziz) “Peritoneal recurrence following appendicectomy for perforated low-grade mucinous appendiceal neoplasms: evaluation of a dual strategy of watch-and-wait and risk-reducing cytoreductive surgery and heated intraperitoneal chemotherapy”. (Published) (B Aljalabneh, J Wild) “Colorectal Liver Metastases - Novel Assessment Tools for Resectability (The CoNoR Study): Results from an International Questionnaire of Hepatopancreatobiliary Surgeons”. (Published) (K Parmar, D O’Reilly, R Jones, M Braun, J Valle, A Renehan) 5.3.2 ASGBI Annual Conference 2021 “Laparoscopy in Emergency General Surgery (The LEGS Study): NELA Database Analysis - Comparison of Outcomes in Laparoscopic versus Open Surgery”. (E-Poster) (K Parmar, E Badrick, L Malcomson, AG Renehan, A Sharma, N Heywood) 5.3.3 European Society of Medical Oncology 2021 “Average cumulative relative dose (ACRD) of adjuvant chemotherapy is more important than average relative dose intensity (ARDI) for colorectal cancer survival, with implications for treating
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
obese patients: the OCTOPUS consortium”. (Oral) (C Slawinski, L Malcomson, H Guo, J Barriuso, A Harkin, T Iveson, R Glynne-Jones, C van de Velde, A Renehan) 5.3.4 Manchester Medical Society 2021 “Radiological patterns and timing of recurrence following complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with Colorectal Cancer Peritoneal Metastases”. (Oral) (S Hassan, Y J Soh, O Aziz, H Clouston, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A G Renehan, R Kochhar) “Peritoneal recurrence following appendicectomy for perforated low-grade mucinous appendiceal neoplasms: evaluation of a dual strategy of watch-and-wait and risk-reducing cytoreductive surgery and heated intraperitoneal chemotherapy”. (Oral) (B Aljalabneh, J Wild) 5.3.5 ACPGBI Annual Conference 2020 “Randomised Controlled Trial of Patients undergoing prehabilitation with Wearables versus Standard of Care before Major Abdominal Cancer Surgery (Trial Registration NCT04047524)”. (E Waller, P Sutton, J Allen, S Rahman, J Saxton, O Aziz) 5.3.6 Manchester Medical Society Student Prize, Poster presentation 2020, “Comprehensive assessment of concordance between peritoneal metastases and primaries of colorectal cancer (CRC) at genomic and transcriptomic level”. (S Belgamwar, Medical Student. Supervisors: Mr O Aziz, Professor S O’Dwyer) 5.3.7 RCS Ed and IAGES meeting (IndoUK surgicon) 2020, IndoUK Surgicon 2020, “Laparoscopic posterior exenteration” (C Selvasekar) 5.3.8 Royal College of Radiology (Lower GI Cancers Debate) 2020, “ Debate: TNT is the new standard of care in locally advanced rectal cancer: Against the motion”. (Oral) (A Renehan) 5.3.9 The Sri Lanka College of Oncology Annual meeting 2020, “Surgical management of colorectal cancer” (C Selvasekar) 5.3.10 International Academic Oncology Meeting , Cancun, 2019 “Laparoscopic HIPEC”. (Oral) (O Aziz) 5.4Project Grant Awards European Society for Medical Oncology (2021-2024), Genomics of appendix adenocarcinoma (J Barriuso & O Aziz, Award value 40,000 Euros) Marie-Skłodowska Curie ITN Early-Stage Researcher (2020-2023) , ValCoRe: Value of Benefit from a new cancer treatment: clinical complete response in rectal cancer (A Renehan, Award value £211,202) CRUK Accelerator Award (2020-2025), Pseudomyxoma peritonei: building a European multicentric cohort to accelerate new therapeutic perspectives (S O’Dwyer, J Barriuso & O Aziz, Award value £2.5m) Christie Charity (2020-2025), Colorectal and Peritoneal Oncology Academy (S O’Dwyer & O Aziz, Award value £375,000)
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
NIHR (2019-2022), Cytoreductive surgery with hyperthermic intraoperative peritoneal chemotherapy versus standard of care in people with peritoneal metastases from colorectal, ovarian or gastric origin: Systematic review and individual participant data meta-analyses of effectiveness and cost-effectiveness (S O’Dwyer & O Aziz, Award value £305,636) NIHR RfPB (2019-2022) , (PrefCoRe): Quantifying and implementing preferences for the treatment of high-risk rectal cancer (A Renehan, Award value £248,879) Ileostomy Association/Medtronic (2019-2021), DiSCO- Defining standards in colorectal prehabilitation. (R Fish, Award value £10,488) MRC National Productivity Investment Fund (2017-2022), Mass Spectrometry Imaging for Colorectal Cancer Subtype Classification (O Aziz, Award value £75,000) NIHR (2017-2020) Single Use Negative pressure dressing for Reduction In Surgical site infection following Emergency laparotomy- the SUNRRISE Trial (H Clouston, Award value £345,669) 5.5Publications 2019-2021 Abudeeb H, Selvasekar CR, O'Dwyer ST, Chakrabarty B, Malcolmson L, Renehan AG, Wilson MS, Aziz O. Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for perforated low-grade appendiceal mucinous neoplasms. Surg Endosc. 2020 Dec ;34(12):5516 5521. doi: 10.1007/s00464-019-07349-x. Epub 2020 Jan 28. PMID: 31993814; PMCID: PMC7644477. Arjona-Sanchez A, Aziz O, Passot G, Salti G, Esquivel J, Van der Speeten K, Piso P, Nedelcut DS, Sommariva A, Yonemura Y, Turaga K, Selvasekar CR, Rodriguez-Ortiz L, Sanchez-Hidalgo JM, Casado-Adam A, Rufian-Peña S, Briceño J, Glehen O. Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry. Eur J Surg Oncol. 2020 Dec 2 :S0748-7983(20)31036-2. doi: 10.1016/j.ejso.2020.11.140. Epub ahead of print. PMID: 33298341. Barriuso J, Nagaraju RT, Belgamwar S, Chakrabarty B, Burghel GJ, Schlecht H, Foster L, Kilgour E, Wallace AJ, Braun M, Dive C, Evans DG, Bristow RG, Saunders MP, O'Dwyer ST, Aziz O. Early Adaptation of Colorectal Cancer Cells to the Peritoneal Cavity Is Associated with Activation of "Stemness" Programs and Local Inflammation. Clin Cancer Res. 2021 Feb 15 ;27(4):1119-1130. doi: 10.1158/1078-0432.CCR-20-3320. Epub 2020 Nov 30. PMID: 33257424. Dames NB, Squire SE, Devlin AB, Fish R, Bisset CN, Tozer P; Respondents to the Sex After Colorectal Surgery Survey. 'Let's talk about sex': a patient-led survey on sexual function after colorectal and pelvic floor surgery. Colorectal Dis. 2021 Feb 22 . doi: 10.1111/codi.15598. Epub ahead of print. PMID: 33615666. Evans T, Aziz O, Chakrabarty B, Wilson MS, Malcomson L, Lavelle C, O'Dwyer ST. Long-term outcomes for patients with peritoneal acellular mucinosis secondary to low grade appendiceal mucinous neoplasms. Eur J Surg Oncol. 2021 Jan ;47(1):188-193. doi: 10.1016/j.ejso.2020.10.020. Epub 2020 Oct 16. PMID: 33092969. Gurusamy K, Vale CL, Pizzo E, Bhanot R, Davidson BR, Mould T, Mughal M, Saunders M, Aziz O, O'Dwyer S. Cytoreductive surgery (CRS) with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) versus standard of care (SoC) in people with peritoneal metastases from
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
colorectal, ovarian or gastric origin: protocol for a systematic review and individual participant data (IPD) meta-analyses of effectiveness and cost-effectiveness. BMJ Open. 2020 May 12 ;10(5):e039314. doi: 10.1136/bmjopen-2020-039314. PMID: 32404398; PMCID: PMC7228534. Lamarca A, Clouston H, Barriuso J, McNamara MG, Frizziero M, Mansoor W, Hubner RA, Manoharan P, O'Dwyer S, Valle JW. Follow-Up Recommendations after Curative Resection of Well-Differentiated Neuroendocrine Tumours: Review of Current Evidence and Clinical Practice. J Clin Med. 2019 Oct 5 ;8(10):1630. doi: 10.3390/jcm8101630. PMID: 31590343; PMCID: PMC6833016. Larentzakis A, O'Dwyer ST, Becker J, Shuweihdi F, Aziz O, Selvasekar CR, Fulford P, Renehan AG, Wilson M. Referral pathways and outcome of patients with colorectal peritoneal metastasis (CRPM). Eur J Surg Oncol. 2019 Dec ;45(12):2310-2315. doi: 10.1016/j.ejso.2019.07.008. Epub 2019 Jul 4. PMID: 31433300. Parkin E, Selvasekar C, Wilson M, Renehan A, O'Dwyer S, Aziz O. Laparoscopic Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (L-CRS/HIPEC) for Perforated Low Grade Appendiceal Mucinous Neoplasm (LAMN II). Ann Surg Oncol. 2019 Jul ;26(7):2285. doi: 10.1245/s10434-019-07277-z. Epub 2019 Apr 15. PMID: 30989495. Pearson I, Blackwell S, Fish R, Daniels S, West M, Mutrie N, Kelly P, Knight S, Fearnhead NS, Moug S. Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation. BMJ Open. 2021 Mar 24 ;11(3):e047235. doi: 10.1136/bmjopen-2020-047235. PMID: 33762250; PMCID: PMC7993327. PelvEx Collaborative. Management strategies for patients with advanced rectal cancer and liver metastases using modified Delphi methodology: results from the PelvEx Collaborative. Colorectal Dis. 2020 Sep ;22(9):1184-1188. doi: 10.1111/codi.15007. Epub 2020 Mar 2. PMID: 32043753. PelvEx Collaborative. Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative. Colorectal Dis. 2020 Oct ;22(10):1258-1262. doi: 10.1111/codi.15064. Epub 2020 May 12. PMID: 32294308. PelvEx Collaborative. The impact of the COVID-19 pandemic on the Management of Locally Advanced Primary/Recurrent Rectal Cancer. Br J Surg. 2020 Oct ;107(11):e547-e548. doi: 10.1002/bjs.11893. Epub 2020 Aug 10. PMID: 32779191; PMCID: PMC7436568. Povey, Powell, Vimalachandran, Howes, Sutton Evaluating the utility of 3D printed models in facilitating pre-operative planning and patient consent in gastrointestinal cancer surgery Accepted by Annals of the Royal College of Surgeons of England Sutton PA, O'Dwyer ST, Barriuso J, Aziz O, Selvasekar CR, Renehan AG, Wilson MS. Indications and outcomes for repeat cytoreductive surgery and heated intra-peritoneal chemotherapy in peritoneal surface malignancy. Surg Oncol. 2021 Apr 20 ;38:101572. doi: 10.1016/j.suronc.2021.101572. Epub ahead of print. PMID: 33915487. Sutton, Sasidharan, Lee, Austin, Solomon. Abdomino-lithotomy sacrectomy for the management of locally advanced and recurrent rectal cancer Accepted by British Journal of Surgery Vallance AE, Harji D, Fearnhead NS; IMPACT collaborative. Making an IMPACT: A priority setting consultation exercise to improve outcomes in patients with locally advanced, recurrent and
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Service Report May 2021 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust
metastatic colorectal cancer. Eur J Surg Oncol. 2019 Sep ;45(9):1567-1574. doi: 10.1016/j.ejso.2019.04.005. Epub 2019 May 7. PMID: 31097310. Waller E, Sutton P, Rahman S, Allen J, Saxton J, Aziz O. Prehabilitation with wearables versus standard of care before major abdominal cancer surgery: a randomised controlled pilot study (trial registration: NCT04047524). Surg Endosc. 2021 Mar 15 . doi: 10.1007/s00464-021-08365-6. Epub ahead of print. PMID: 33723969. 5.6Books (Chapters) “Colorectal Surgery 6th Edition: A Companion to Specialist Surgical Practice”, Advanced and recurrent colorectal cancer, Clark, Elsevier (O Aziz) “Cracking the Intercollegiate General Surgery FRCS Viva: A Revision guide 2nd Edition”, Chapter 3 Emergency Surgery and Chapter 4 General Surgery, Tang, CRC Press (R Fish & P Sutton) “Research Skills for the Modern Surgeon”, Sutton, Nielsen (P Sutton) 6 The Peritoneal Tumour Charitable fund Since 2016 we have assigned over £500,000 to support several initiatives for patients with PMP, appendix and peritoneal tumours. We are extremely grateful to all of our donors for their unfailing support and generous donations. These are some of the achievements and future opportunities: - 6.1 Increased awareness has resulted in more referrals Better understanding of the appendix as the source of disease has led more professionals and patients to check the pathology in the appendix and request information and referrals to the reference centres. Earlier referral has led to a greater proportion of patients being seen with localised and less advanced disease. This has allowed us to offer preventative surgery now described as ‘risk reducing’ surgery to stop the development of full blown PMP. In a number of cases this surgery can be performed using keyhole techniques which have been pioneered at The Christie. Specialist equipment is required to undertake these procedures and video transmission of the procedures has been created to educate other centres in these techniques. Using these methods patients have a shorter stay in hospital and return to work and full activity much quicker. Charitable funds have allowed the purchase of additional surgical equipment which in turn facilitate We recognise that the diagnosis and treatment of patients with PMP and appendix tumours has specific stresses. This is often because the conditions are rare and those dealing with it feel isolated and unsupported by the professionals and the NHS. Identifying where and when in the journey the key milestones are, allows us to direct resources to support patients. We have identified financial burdens on families and are working with charities to offer accommodation for families and supporters during hospital spells. In addition, support with transport to attend for tests and treatments takes the worry from those with limited resources. In particular, through support from the Pseudomyxoma Survivor charity, we have been able to agree a contract with StayCity, Manchester to provide offsite accommodation for patients’ families whilst they undergo their inpatient treatment. In addition, Pseudomyxoma Survivor have donated gift boxes for patients on the ward to help improve their stay. the development and use of novel surgical procedures. 6.2 Improving the patient journey and experience
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